Failure to Communicate and Implement Updated Diet Order
Penalty
Summary
The facility failed to follow the prescribed diet order for a resident with diagnoses including type 2 diabetes mellitus, hyperlipidemia, and cerebral infarction. The resident was initially placed on a Consistent Carbohydrate Diet (CCD) with No Added Salt (NAS), regular texture, and regular/thin liquids, following a swallow evaluation that cleared her for a regular diet. Despite this, the resident continued to be served a mechanical soft diet with chopped meats. Documentation showed that the resident had requested a change to whole foods, and a speech-language pathologist (SLP) had evaluated and approved the upgrade to a regular diet. The diet requisition form reflected this change, but the dietary department was not notified of the updated order. Observations confirmed that the resident was still being served chopped meats after the diet order had been changed. Interviews with dietary staff and the dietary manager revealed a lack of awareness regarding the updated diet order, with the dietary manager believing the resident was still on a mechanical soft diet. The SLP confirmed the resident was safe for a regular diet, and the Director of Nursing acknowledged that the dietary department had not been informed of the change, resulting in the resident not receiving the prescribed diet.